Reminder to Physicians & Billing Companies: Verify Patient’s Coordination of Benefits!

April 19, 2012

The Centers for Medicaid & Medicare (CMS) recently released an MLN Matters Article that highlights the Medicare Secondary Payer (MSP) rules. These rules delineate the circumstances in which Medicare will only make payment after another insurance carrier issues the primary payment. All too frequently, physicians and their billing companies will receive denials from Medicare due to a coordination of benefits (COB) issue. As examples, Medicare will not make primary payment on a claim if there is any open workers’ compensation case on file for the patient, or if the patient or patient’s spouse is currently employed. In order to alleviate denials and delays in payment receipt, physicians, healthcare providers, and billing services should help to educate patients about coordination of benefits issues. It may be helpful to post signs or remind patients that they must contact their insurance companies (both Medicare AND the other payer) to coordinate benefits in any of the following situations:

  • If there is a change in patient’s employment status, including retirement and changes in health insurance companies.
  • If there is a change in the PATIENT’S SPOUSE has a change in employment status.
  • If an attorney has taken legal action on patient’s behalf for any claim.
  • If the patient has been involved in an automobile accident or a workers’ compensation case.

It is then the provider’s responsibility (and the responsibility of the billing service) to submit secondary claims to Medicare with all available information on the primary payment (including the Explanation of Benefits received from the primary payer). Medicare uses this information to determine the appropriate secondary payment amount.

For the complete Medicare Secondary Payer (MSP) manual, including all of the detailed circumstances in which Medicare is the secondary payer, visit the CMS website for a downloadable PDF.